Thomas Pringle (Donegal South West, Independent)
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I thank the Ceann Comhairle for selecting this Topical Issue for discussion as it is an important matter that is causing grave concern throughout County Donegal. As the Minister will be aware, Nowdoc has provided out-of-hours general practitioner, GP, services in County Donegal since 2001. Two years ago, when the out-of-hours service was threatened with closure, Caredoc started to provide GP out-of-hour services, while Nowdoc continued to provide the Health Service Executive back-up service for the out-of-hours service. In recent weeks, Caredoc has proposed changes to the service, under which two of the current three centres would close for what is known as the "red eye shift", which extends from midnight until 9 a.m. The doctors in question would then be redeployed to a centre in Letterkenny, which would cover an area stretching from Gweebarra Bridge to Malin Head, which is probably larger than most counties. This has created serious concerns about the level of service that will be available to people in the relevant areas, especially west Donegal and the Inishowen Peninsula, and how the service will be managed.

Caredoc has claimed the changes are being made because an insufficient number of doctors is available to cover the so-called red eye shift. I believe the proposal is a cost-saving measure aimed at reducing the overheads in running the service. Nowdoc's call-out ratio and service indicators are very good and it provides a service in a timely fashion to those who urgently need care. People are concerned that this excellent out-of-hours general practitioner service will be undermined and further reduced in future.

Dinny McGinley (Donegal South West, Fine Gael)
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When the Nowdoc was being established in 2000-01, there was considerable apprehension among service users that they would lose contact with their family doctor and a gulf would emerge between service users and their general practitioners. However, users are now confident in and happy with the service. Any proposal to change the delivery of a health service causes considerable concern and anxiety among its users.

Three general practitioners currently provide an out-of-hours service in the region, one each in Carndonagh, Letterkenny and Derrybeg, respectively. It has been proposed to reduce the number of GPs operating the service to two and base both in Letterkenny. As a general practitioner, the Minister will be aware that when someone is struck with a serious illness between midnight and 8 a.m., time is of the essence. Deputies Thomas Pringle, Pearse Doherty and I all live about one hour's drive from Letterkenny hospital. Moreover, there are inhabited islands off the coast of Donegal. Tory Island has a population of 200 and Arranmore has a population of approximately 600. There is no doubt, therefore, that if the proposed changes are implemented, the level of service in County Donegal will be reduced.

Deputies Pringle, Doherty and I all attended a public meeting last Monday night. All those in attendance were apprehensive and concerned. It was significant that the four general practitioners present did not express confidence in the proposed new service. As the specialists working at the coalface, their views should be taken into consideration before any changes are made to the service.

Pearse Doherty (Donegal South West, Sinn Fein)
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I thank the Ceann Comhairle for selecting this matter for discussion.

The Minister should not lose sight of the significance of Deputies McGinley and Pringle as well as myself speaking with one voice on this issue, as it is rare that this occurs in the House. This issue goes to the core of services to rural communities. Deputy Mac Lochlainn asked me to express his support for the position the two previous speakers and I are taking on this matter, which affects west County Donegal and the Inishowen Peninsula. Under the current proposal, Derrybeg and Carndonagh will lose a permanent general practitioner service from midnight until 9 a.m. in two phases. In the first phase, the service will be lost from Sunday until Thursday, while in the second, which would be implemented in the summer, the service would be lost completely.

This issue goes to the core of the type of service people want to maintain in their area. They do not want the current service to be diminished as it would result in many people waiting for 45 minutes for a doctor to arrive. The Minister has visited west Donegal. In winter months, the main road to the area is frequently closed due to frost and so forth. People in the area do not want to take risks.

The out-of-hours general practitioner service also serves island communities. I wrote to the Minister and chief executive officer of the Health Service Executive in February welcoming an intervention of the HSE in appointing an interlocutor to negotiate between Caredoc, the HSE and general practitioners on the unfolding crisis in the out-of-hours service. The problem is that Caredoc was about to withdraw from the out-of-hours service in February.

GPs say one of the big problems is that the HSE removed the financial support that was there to fund these doctors during the red-eye shift about five years ago. Caredoc is losing a huge amount of money as a result of this and, therefore, wants to reduce the number of doctors from three to two. It will have its own version of the story. I have been dealing with this since 2011 and raised it umpteen times in the Chamber.

I want to say go mbeidh sé inglactha ag pobal na Gaeltachta agus pobal Inis Eoghain má théann sé seo ar aghaidh. Beidh go leor daoine agus go leor agóidí le feiceáil ar na sráideanna má théann sé ar aghaidh. Tá súil agam go n-éisteoidh an tAire. I hope the Minister listens to the concerns of the public and does not wash his hands of the matter by saying it is an issue for the HSE. This is an issue concerning services to rural areas. I could tell the Minister stories about lives that were saved as a result of the NowDoc service being very close to the individuals involved. I hope a solution can be found to this problem.

Leo Varadkar (Dublin West, Fine Gael)
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I thank Deputies McGinley, Doherty and Pringle for raising the issue as it gives me an opportunity to update the House on the matter. I am taking the debate on behalf of my colleague, the Minister of State, Deputy Kathleen Lynch, who is on Government business elsewhere.

The NowDoc GP out-of-hours service is a partnership arrangement between the GPs affiliated with the NowDoc service and the HSE. The service provides out-of-hours GP care to patients in the north-west catchment area. In November 2013, the GPs engaged with Caredoc Ltd. to manage the GP out-of-hours services in Donegal, south Leitrim and north Roscommon on their behalf. The HSE entered into discussion with Caredoc and the GPs regarding a formal service arrangement in November 2014. A number of issues were discussed to facilitate the development of a sustainable and efficient service into the future. These included further development of the clinical governance structures, ICT development, liaison and monitoring arrangements, GP deployment arrangements and funding. An independent facilitator was put in place in early 2015 with a view to having a memorandum of agreement signed by the parties by the end of May 2015.

It was also agreed that the issues of GP deployment and funding could only be addressed through a comprehensive review of the current call activity and GP resources. The Caredoc GP clinical lead reviewed the available data and in recent weeks and the HSE has validated this to ensure that call activity data is accurate for the agreed review period and reflects the predicted call activity levels. The completed review indicates that there are few calls after midnight on the red-eye shift and that the current level of GP resources allocated to this period could be safely reduced while maintaining the service response times in line with the current performance standards and well within the response time standards of the Royal College of General Practitioners. The review also indicates that the red-eye GP resource in Carrick-on-Shannon and Mountcharles would remain as per the current arrangements, with the potential to reduce the duty GPs in the north Donegal area by one during the red-eye period. This measure is also being considered in the context of providing GP cover arrangements that are sustainable into the future and to assist in addressing difficulties that currently exist in recruiting sufficiently qualified and vocationally trained GPs to cover red-eye shifts. The possibility of having such a reduction implemented over two phases has also been considered to allow phase 1 to be analysed in detail before proceeding to phase 2. The arrangements for phase 1 would see a reduction in cover for the five weekday nights only, as these are not as busy.

Following the review, the GPs and Caredoc have indicated their intention to submit a formal recommendation regarding GP deployment in the out-of-hours service. As part of the consultation process with stakeholders, the HSE, the GP clinical lead and Caredoc personnel met with Oireachtas Members and Donegal County Council members of the Western Health Forum last Friday to discuss the review process and possible outcomes. The HSE, GPs and Caredoc continued their discussions today. All parties will now reflect on the contributions from elected representatives to ensure that agreement can be reached on service delivery arrangements so that services continue to be provided in a safe and efficient manner. All services will remain as per the current arrangements until this process is concluded.

Thomas Pringle (Donegal South West, Independent)
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The Minister's response simply outlines what has happened to date in relation to the service. The one thing that was missing from the reply was that while we met with Caredoc and NowDoc last Friday to discuss the service, there was no consultation with any service user on the changes that are taking place. It is outrageous that health services would envisage such a major change that changes the whole structure and functioning of this GP out-of-hours service without that consultation. The GPs have a contract to provide an out-of-hours service to their clients in a certain way, but they do not bother to consult with them in relation to it.

The service must be maintained as it is. The Minister refers to the call-out figures. If one looks at the numbers, it may not justify it, but what value are we going to put on the fact that one person could be saved? I have never had an accident driving my car, but it does not mean I stop wearing my seat belt. The service must be provided and security must be provided to the community. This must be figured into the consultation process that is taking place. I am sad to say it is lacking from the consultation so far. The service must be maintained, as must the confidence of the public in Donegal.

Dinny McGinley (Donegal South West, Fine Gael)
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What shocked me and, I am sure, my colleagues is that this was presented to us last Friday almost as a fait accompli. There was very little consultation with users, public representatives or others. Even members of the health forum, on which five Donegal members sit, were not aware of the changes being proposed. Does the Minister agree that the delivery of a health service affects and concerns everyone and that there should be far more consultation? I would like to get the Minister's view of the fact that there will be a serious reduction in the level and quality of service if this goes ahead. Deputy Doherty has already said that NowDoc has saved lives. Deputy Doherty and I know that, unfortunately, people from our own area have passed away on the way to Letterkenny. All of these things must be taken into consideration. While the Minister says discussions and negotiations are continuing, I hope the views of the Members here, the people we met last Monday and of people in general and, in particular, of the GPs will not be overlooked when the final decision is arrived at.

Pearse Doherty (Donegal South West, Sinn Fein)
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I have been around long enough to recognise a box-ticking exercise. With no disrespect to those who were present at the meeting, it was a box-ticking exercise. The reason the meeting took place was that Deputy Pringle and I, among others, including the public, were raising concerns in the media for a number of weeks in relation to NowDoc. We had a structured, normal quarterly meeting with the HSE at which this item was on the agenda. We were then told this was part of the consultation. Does the Minister know that in 2011 NowDoc made the very same proposal to the HSE? The HSE then appointed a three-person panel to review the safety of the proposal and that panel rejected it on safety grounds. I got a letter from the HSE saying that when the GPs agreed their proposal with Caredoc, it would be independently assessed on a health basis. I asked the acting HSE manager who would carry out the review and was told that the meeting on Friday with us, the elected representatives, was part of that independent assessment. How the hell can I as a public representative assess the safety of reducing the NowDoc service from three doctors to two?

There are two things I ask the Minister to do. First, I ask him to clarify whether the HSE is providing any funds to fund GP cover out of hours anywhere in the country. Second, I ask the Minister to ensure that an independent safety audit is done in relation to the NowDoc proposal outside of the GPs, the clinical lead, Caredoc, and the HSE, who have been involved in that tripartite discussion since February.

Leo Varadkar (Dublin West, Fine Gael)
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I hear the Deputies' concerns and acknowledge their desire for further consultation. I understand that there is always anxiety when there is any change to health services, even where the change is for the better or results in a higher quality service. The HSE provides funding for out-of-hours services all over the country.

Pearse Doherty (Donegal South West, Sinn Fein)
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Does it provide funding for GP cover directly?

Leo Varadkar (Dublin West, Fine Gael)
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Deputy Doherty is eating into my time; I may not be able to answer all the questions the Deputies asked. I am familiar with the NowDoc service, having spent an evening providing it when I did my undergraduate GP training in Carndonagh a long time ago. It is a very good service. It is important to bear in mind that GPs are a scarce resource and their time must be used efficiently. It does not make sense to have a GP up all night seeing one or two patients when the next day there is no one to see the 12 or 15 patients he or she would have seen had he or she been rostered during the day instead.

It is particularly difficult to get actual qualified GPs, vocationally trained GPs, to cover the red-eye shift. What happens instead all over the country is that people who are not fully qualified GPs, who are other types of doctor, fill in at night time and that is a quality issue as well which needs to be borne in mind. It is better to have one or two properly qualified GPs providing a service than to have three who are not actually GPs but are doctors without a general practitioner qualification. Of course this is ultimately a local matter and has to be resolved by agreement of KDOC, the GPs in Donegal and the HSE locally. It is not a decision that is subject to ministerial approval, sign-off or a veto.